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7SVWRCB, January 2002 Page 1 of 7 Secondary Containment Testing Repo fRA,Zulu This form is intended for use by contractors performing periodic testing of UST secondary cpropriate pages of this form to report results for all components tested. The completed form, written test procedu is (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: CHP Stockton Date of Testing: 3-18-10 Facility Address: 3330 N. Ad Art Rd. Stockton, CA 95215 Facility Contact: Phone: Date Local Agency Was Notified of Testing : 3/8/10 Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: CA. HAZARDOUS SERVICES,INC Technician Conducting Test: Brian Halfwassen Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester License Number: 734854 ICC Technician# 5006847 -UT Manufacturer Training Manufacturer Component(s) Date Training Expires INCON STS SUMP TESTER 9-17-11 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: 2-55 Gallon Drums With Test Water Left On Site CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements I Technician's Signature: -- _ . Date: 3-18-10 ►� Q ■00( ■00 ■00■ ' �� Q ■00' ■00 ■00 �1 ■�� wiin�lI SpillFill ►� 000■ 0000 Vapor �� 0■ 00 0000 Lin6,13aoindary►t ■000' 00©0 Vapor Return ro �� 000 ODDD I MOM If hydrostatic testing was performed, describe what was done with the water after completion of tests: 2-55 Gallon Drums With Test Water Left On Site CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements I Technician's Signature: -- _ . Date: 3-18-10